CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB014

Prenatal Screening (Nongenetic)

Defines BCBSOK reimbursement criteria for routine prenatal (nongenetic) laboratory screening tests and related coding guidance for providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLAB014

Change TypeRevisedAddedClarified

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and use appropriate HIPAA-approved codes; BCBSOK may request additional documentation and applies claim review and code edit protocols.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information was revised to add cross-references to other CPCP policies (thyroid, fetal aneuploidy, vector-borne infections) and to remove prenatal fetal aneuploidy screening language and certain thyroid and Zika testing language.

A specific reimbursement statement that for individuals with a normal pregnancy without complications, hCG testing is not reimbursable.

Terminology was changed from 'women' to 'individuals' throughout for inclusivity; other wording edits were made for clarity.

15+routine prenatal screening items enumerated

1.0policy version

80055–0167Uexample procedure codes included

7/17/2023

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

latest committee approval

Coverage Criteria for Routine Prenatal Screening

Routine prenatal screening items and specific reimbursement criteria

Covered when ALL of the following routine prenatal screening tests are indicated:

ALL of the following

HIV screening
Chlamydia trachomatis screening
Neisseria gonorrhea screening
Hepatitis B screening
Syphilis screening
Hepatitis C screening
Screening for bacteriuria
Screening for type 2 diabetes at the first prenatal visit
Screening for gestational diabetes during gestational weeks 24–28 (and at the first prenatal visit if risk factors are present)gestational weeks 24–28; also at first prenatal visit if risk factors present
Determination of blood type, Rh(D) status, and antibody status at the first prenatal visit; repeat Rh(D) antibody testing at 24–28 weeks for unsensitized Rh(D)-negative individuals unless the biological father is known Rh(D)-negative
Anemia screening (CBC or hemoglobin/hematocrit with mean corpuscular volume)
Group B Streptococcus screening once (recommended at 36–37 weeks)
Urinalysis and urine culture
Rubella antibody testing
Varicella immunity testing
TB screening for individuals at high risk for tuberculosis

Exceptions and exclusions — reimbursable exceptions and non-covered tests

Exceptions, special-case reimbursable services, and explicit non-covered tests:

ANY of the following

Rapid HIV testing in labor
May be reimbursable when the pregnant individual presents in active labor with undocumented HIV status
ALL of the following
- Singleton or twin gestation
- Intact membranes
- Cervical dilation <3 cm

High-risk re-screening criteria — third trimester re-screening rules

Third-trimester re-screening for sexually transmitted infections and HIV may be reimbursable when ANY of the following high-risk criteria apply:

ANY of the following

Individual under 25 years of age
New or multiple sexual partners
History of sexually transmitted infections (examples: Bacterial Vaginosis, Chancroid, Chlamydia, Gonorrhea, Genital Herpes, Hepatitis B, Hepatitis C, HIV/AIDS, Human Papillomavirus, Lymphogranuloma Venereum, Syphilis, Trichomoniasis)
Past or current injection drug use

Coding and Procedure Codes

Example procedure codes list (not exhaustive)CPT

80055	80055
80081	80081
81001	81001
81002	81002
81003	81003
81007	81007
81015	81015
82677	82677
82731	82731
82947	82947

1–10 of 75

1/8

Gestational window for GDM screening

Gestational windowGestational weeks 24–28 for routine gestational diabetes mellitus (GDM) screening; also at the first prenatal visit when risk factors for pregestational diabetes are present

Associated repeat testingRepeat screening at first prenatal visit applies when risk factors for diabetes (e.g., undiagnosed type 2 diabetes risk) are present

Context in routine panelListed as item (i) among routine prenatal screening reimbursements

Use of fetal fibronectin (FFN) — reimbursable conditions and gestational limits

Coverage conditionsFetal fibronectin (FFN) assays reimbursable only when ALL listed criteria are met

Gestational limits

Provider Documentation, Claims, and Authorization

Documentation Required

Documentation and claims submission

Providers are responsible for submission of accurate documentation of services performed. Submit claims using valid HIPAA-approved code sets and appropriate code combinations (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, UB, etc.) and follow industry-standard coding guidelines, including AMA CPT guidance, CMS NCCI edits/CCI tables, and other CMS guidelines. Claims are subject to code edit protocols and review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, BCBSOK may require additional documentation — providers are urged to submit any requested records to support medical necessity and accurate coding.

Use HIPAA-approved code sets: CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, UB
Follow coding guidance: AMA CPT, CPT Assistant, CMS NCCI/CCI, DRG rules
Be prepared to submit additional documentation on request

Prior Authorization

Prior authorization / reimbursement conditions

Prior authorization is not described as routinely required for routine prenatal infectious disease screening in this policy; however, reimbursement for third‑trimester re‑screening and certain rapid HIV testing is conditional. Third‑trimester re‑screening for Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and/or HIV may be reimbursable when the pregnant individual meets high‑risk criteria (see items). Rapid HIV testing and any services requiring review may be subject to reimbursement rules and documentation requirements; providers should check member benefit documents and submit supporting documentation when requested.

Definitions and Covered Services References

Covered Services / Plan documents

Governing documentsPlan documents (e.g., Certificates, benefit booklets, Summary Plan Descriptions) govern when there is a conflict between this CPCP and a member's coverage

Provider contractsIf a conflict arises between a CPCP and a provider contract, the provider contract will govern

BCBSOK discretionBCBSOK may use reasonable discretion interpreting and applying this policy and has full and final discretionary authority to the extent provided under plan documents

High‑risk criteria for third‑trimester re‑screening

Age criterionIndividual under 25 years of age

Sexual partnersNew or multiple sexual partners

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrenatal Screening (Nongenetic)

Policy CodePolicy CPCPLAB014

Change TypeRevisedAddedClarified

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and use appropriate HIPAA-approved codes; BCBSOK may request additional documentation and applies claim review and code edit protocols.

SourceLink

On This Page

Symptoms suggestive of preterm labor between 24 and <35 weeks' gestation

Human chorionic gonadotropin (hCG) testing

Not reimbursable for individuals with a normal pregnancy without complications

Serial salivary estriol monitoring

Not reimbursable as a technique for preterm labor risk assessment

All other FFN assay indications not described above

Not reimbursable

Symptoms suggestive of preterm labor between 24 and less than 35 weeks' gestation

Clinical criteriaIntact membranes; cervical dilation <3 cm; singleton or twin gestation; symptoms of preterm labor

Non‑reimbursable situationsFFN assays not reimbursable for situations other than the ALL‑criteria scenario above

Third‑trimester re‑screening reimbursable when ANY high‑risk criteria met: age <25; new or multiple sexual partners; history of STIs (including BV, Chancroid, Chlamydia, Gonorrhea, Genital Herpes, Hepatitis B/C, HIV/AIDS, HPV, LGV, Syphilis, Trichomoniasis); past or current injection drug use
Routine prenatal screening reimbursable includes HIV, Chlamydia, Gonorrhea, Hepatitis B, Syphilis, Hepatitis C, bacteriuria, type 2 diabetes at first visit, gestational diabetes at 24–28 weeks (or earlier if risk factors), blood type/Rh(D)/antibody testing (with repeat Rh(D) antibody testing at 24–28 weeks for unsensitized Rh(D)‑negative women unless father known Rh(D)‑negative), anemia screening (CBC/Hgb/Hct with MCV), Group B strep at 36–37 weeks, urinalysis/urine culture, rubella and varicella immunity testing, and TB screening when high risk
Verify member coverage and prior authorization requirements per plan documents; submit required documentation to support reimbursement

STI historyHistory of sexually transmitted infections (e.g., Chlamydia, Gonorrhea, Syphilis, HIV, Hepatitis B/C, HPV, Trichomoniasis, BV, etc.)

Injection drug usePast or current injection drug use

Use for third‑trimester re‑screeningAny one of these high‑risk criteria may justify reimbursable third‑trimester re‑screening for chlamydia, gonorrhea, syphilis, and/or HIV